Rani Khatib

Is Adherence to Imatinib Mesylate Treatment Among Patients with Chronic Myeloid Leukemia Associated with Better Clinical Outcomes in Qatar

Background Despite the revolutionary success of introducing tyrosine kinase inhibitors (TKIs), such as imatinib mesylate (IM), for treating chronic myeloid leukemia (CML), a substantial proportion of patients’ treatments fail. Aim This study investigates the correlation between patient adherence and failure of TKIs’ treatment in a follow-up study. Methods This is a follow-up study of a new cohort of CML patients. Adherence to IM is assessed using the Medication Event Monitoring System (MEMS 6 TrackCap, AARDEX Ltd). The 9-item Morisky Medication Adherence Scale, medication possession ratio (MPR) calculation, and the electronic medical records are used for identifying potential factors that influence adherence. Clinical outcomes are assessed according to the European LeukemiaNet 2013 guidelines via reverse transcriptase quantitative polymerase chain reaction measurement of the level of BCR-ABL1 transcripts in peripheral blood. Response is classified at the hematological, cytogenetic, and molecular levels into optimal, suboptimal, or failure. Results A total of 36 CML patients (5 citizens and 31 noncitizen residents) consented to participate in the study. The overall mean MEMS score was 89. Of the 36 patients, 22 (61%) were classified as adherent (mean: 95) and 14 (39%) were classified as nonadherent (mean: 80.2). Adherent patients were significantly more likely to obtain optimal response (95%) compared to the nonadherent group (14.3%; P < 0.0001). The rate of poor adherence was as high as 39% using MEMS, which correlates with 37% treatment failure rate. The survey results show that 97% of patients increased the IM dose by themselves when they felt unwell and 31% of them took the missing IM dose when they remembered. Other factors known to influence adherence show that half of patients developed one or more side effects, 65% of patients experienced lack of funds, 13% of patients declared unavailability of the drug in the NCCCR pharmacy, and 72% of patients believed that IM would cure the disease. The MPR results reveal that 16% of patients had poor access to treatment through the hospital pharmacy. Discussion and Conclusion This is the first prospective study to evaluate CML patients’ adherence and response to IM in Qatar. The high rate of treatment failure observed in Qatar is explained by poor adherence. An economic factor (unaffordable drug prices) is one of the main causes of nonadherence and efforts should be made locally to improve access to medication for cancer diseases. Other risk factors associated with poor adherence could be improved by close monitoring and dose adjustment. Monitoring risk factors for poor adherence and patient education that include direct communication between the health-care teams, doctors, nurses, pharmacists, and patients are essential components for maximizing the benefits of TKI therapy and could rectify this problem. The preliminary results show that patients’ response to treatment may be directly linked to patients’ adherence to treatment. However, further in-depth and specific analysis may be necessary in a larger cohort.

Evaluation of the Methods and Management of Acute Coronary Events (EMMACE)-3: protocol for a longitudinal study

Introduction Patients with cardiovascular disease are living longer and are more frequently accessing healthcare resources. The Evaluation of the Methods and Management of Acute Coronary Events (EMMACE)-3 national study is designed to improve understanding of the effect of quality of care on health-related outcomes for patients hospitalised with acute coronary syndrome (ACS). Methods and analysis EMMACE-3 is a longitudinal study of 5556 patients hospitalised with an ACS in England. The study collects repeated measures of health-related quality of life, information about medications and patient adherence profiles, a survey of hospital facilities, and morbidity and mortality data from linkages to multiple electronic health records. Together with EMMACE-3X and EMMACE-4, EMMACE-3 will assimilate detailed information for about 13 000 patients across more than 60 hospitals in England. Ethics and dissemination EMMACE-3 was given a favourable ethical opinion by Leeds (West) Research Ethics committee (REC reference: 10/H131374). On successful application, study data will be shared with academic collaborators. The findings from EMMACE-3 will be disseminated through peer-reviewed publications, at scientific conferences, the media, and through patient and public involvement. Study registration number ClinicalTrials.gov Identifier: NCT01808027. Information about the study is also available at EMMACE.org.

Take real world issues into account

Pink and colleagues’ analysis of the economics of dabigatran is flawed by several real world issues that were not considered.1 Firstly, the price of dabigatran will fall as competitive drugs are licensed. Secondly, the cost of stopping international normalised ratio (INR) monitoring depends on whether warfarin clinics continue to run but …

A competency framework for clinical pharmacists and heart failure

Heart failure is an escalating ‘pandemic’ with malignant outcomes. Clinical pharmacist heart failure services have been developing for the past two decades. However, little clarity is available on the additional advanced knowledge, skills and experience needed for pharmacists to practice safely and competently. We aimed to provide an expert consensus on the minimum competencies necessary for clinical pharmacists to deliver appropriate care to patients with heart failure.

4 Iron deficiency in heart failure patients in england: insights from analysis of hospital episode statistics

Introduction Iron deficiency (ID) has been shown to be present in about 50% of patients with heart failure (HF). Associated with a poor quality of life, impaired effort tolerance, and increased mortality, ID responds to appropriately provided iron therapy. In those admitted with HF, screening for ID is inconsistent, and the impact of this condition is uncertain. Methods For the period April 2013 to March 2016 (2013–16), Hospital Episode Statistics (HES) data from all NHS hospitals in England were evaluated for spells in which HF was coded as the primary diagnosis. This was based on the International Statistical Classification of Diseases and Related Health Problems (ICD-10) codes: I11.0 (hypertensive heart disease with [congestive] heart failure; I25.5 (ischaemic cardiomyopathy); I42.0 (dilated cardiomyopathy); I42.9 (cardiomyopathy, unspecified); I50.0 (congestive heart failure); I50.1 (left ventricular failure); and I50.9 (heart failure, unspecified). These records were then categorised according to those with or without a secondary diagnosis of ID or iron deficiency anaemia (IDA), based on ICD-10 codes E611 (latent ID), D500 (IDA secondary to blood loss [chronic]), D508 (other IDA), and D509 (IDA unspecified). Results In 2013–16, there were 2 02 444 hospital spells in England attributed to a primary diagnosis of HF. Of these, 28 727 spells (14.2%) had a secondary diagnosis of ID/IDA, and 1 73 717 (85.8%) did not. Spells with a secondary diagnosis of IDA/ID were more likely to be encountered in females (p<0.0001) and older patients (p<0.0001); were more likely to be unplanned (95.9% vs 86.4% – difference 9.5%: 95% CIs: 9.2%, 8%); had a longer mean length of stay (16.5 vs 13.1 days – difference 3.4 days: 95% CIs: 3.2, 3.6); and had a higher readmission rate within 30 days under the same ICD-10 code (14.2% vs 12.1% – difference 2.1%: 95%CIs: 1.8%, 2.6%). The total cost associated with all hospital admissions with a primary diagnosis of HF was £553.3 million, equivalent to £2733 per spell. HF hospital spells with a secondary diagnosis of ID/IDA were significantly more expensive than those without (cost difference: £138 per spell [95% confidence interval {CI}: £98, £178]). Unplanned spells with a secondary diagnosis of ID/IDA were even more expensive compared to those without ID/IDA (cost difference: £217 [95% CI: £181, £253]). Conclusions In this analysis of HES data from England, about 14% of hospital spells coded with a primary diagnosis of HF included ID/IDA in the secondary position. These spells were longer, more expensive, and more likely to lead to readmission. Although probably under recognised in those admitted with HF, ID/IDA appears to be a significant comorbidity associated with poorer outcomes across the health economy.

An unusual case of atrial fibrillation

A 46 year old female presented to an emergency department (ED) late in the evening complaining of palpitations. The patient reported ongoing symptoms for 30minutes at the time of presentation and had self-referred to the ED. On arrival, her main symptoms were ‘pounding heart’, a fluttering feeling in the throat and mild chest discomfort. The patient was triaged as category 2 using the Manchester Triage Scale and a 12-lead ECG confirmed Atrial Fibrillation (AF). The patient was admitted to the resuscitation area to a monitored bed.

Optimal dosing of angiotensin-converting enzyme inhibitors and β-blockers for acute coronary syndrome: up-titration remains a challenge

Objectives Suboptimal dosing of angiotensin-converting enzyme inhibitors and β-blockers limits the mortality benefit for acute coronary syndrome patients. Recent National Institute for Health and Care Excellence (NICE) guidelines emphasise prompt initiation and up-titration from inpatient to community care to achieve this. The aim of this study was to assess the impact of simple interventions on inpatient and community up-titration of bisoprolol and ramipril for acute coronary syndrome patients admitted to Leeds General Infirmary. Methods An initial prospective audit of 37 acute coronary syndrome patients admitted to Leeds General Infirmary in January 2013 assessed inpatient up-titration of bisoprolol and ramipril, discharge advice and doses at 6 weeks after discharge. Following a collective multidisciplinary effort with education, posters and discharge advice templates, a re-audit of 34 acute coronary syndrome patients admitted from November to December 2014 assessed the impact of these interventions. The independent samples t test was used to compare the mean difference between doses of ramipril and bisoprolol from initiation to discharge to dose at 6 weeks after discharge before and after intervention. Results There was a statistically significant improvement in the mean difference from initiation to discharge dose for both ramipril and bisoprolol (p=0.012 and p=0.017, respectively). However, there was little difference in community up-titration despite a 68% improvement in discharge advice. Conclusions Simple multidisciplinary interventions improved inpatient up-titration of ramipril and bisoprolol but continued up-titration to achieve the target doses remains a challenge in primary care. Acute coronary syndrome patients are precluded from maximum mortality benefit due to suboptimal dosing after discharge.

Dose optimisation following myocardial infarction: MEDICINES MANAGEMENT

Dose optimisation of medicines for secondary prevention of MI provides evidence-based benefits, but studies show that ACE inhibitors and beta-blockers are prescribed at suboptimal doses on discharge and are not appropriately up-titrated thereafter. Here we look at the reasons why and the possible solutions.Dose optimisation of medicines for secondary prevention of MI provides evidence‐based benefits, but studies show that ACE inhibitors and beta‐blockers are prescribed at suboptimal doses on discharge and are not appropriately up‐titrated thereafter. Here we look at the reasons why and the possible solutions.

Dose optimisation following myocardial infarction

Dose optimisation of medicines for secondary prevention of MI provides evidence-based benefits, but studies show that ACE inhibitors and beta-blockers are prescribed at suboptimal doses on discharge and are not appropriately up-titrated thereafter. Here we look at the reasons why and the possible solutions.Dose optimisation of medicines for secondary prevention of MI provides evidence‐based benefits, but studies show that ACE inhibitors and beta‐blockers are prescribed at suboptimal doses on discharge and are not appropriately up‐titrated thereafter. Here we look at the reasons why and the possible solutions.

Pharmacology of Medications Used in the Treatment of Atherosclerotic Cardiovascular Disease

Atherosclerosis initially occurs asymptomatically, but can progress to cause symptoms of angina and may culminate in coronary thrombosis and acute myocardial infarction (MI). This article will discuss the medications used in atherosclerotic cardiovascular disease, focusing on those used in the acute setting following MI, as well as those used in primary and secondary prevention of cardiovascular disease. The following areas will be covered: mechanism of action, pharmacokinetics, adverse drug reactions and interactions, and practical tips for clinical use.